Adult circumcision can be
performed under local or regional anesthesia. Medical indications for this
procedure include phimosis, paraphimosis, recurrent balanitis and posthitis
(inflammation of the prepuce). Nonmedical reasons may be social, cultural,
personal or religious. The procedure is commonly performed using either the
dorsal slit or the sleeve technique. The dorsal slit is especially useful in
patients who have phimosis. The sleeve technique may provide better control of
bleeding in patients with large subcutaneous veins. A dorsal penile nerve
block, with or without a circumferential penile block, provides adequate
anesthesia. Informed consent must be obtained. Possible complications of adult
circumcision include infection, bleeding, poor cosmetic results and a change in
sensation during intercourse.

Circumcision is performed on an
estimated one out of six male newborns worldwide.1 Over 60 percent of male newborns were circumcised
in the United States in 1992.2 Circumcision
in adults is performed much less often; however, accurate statistics are not
available. Adult patients often have a medical indication for the procedure,
but circumcision may also be done for social or purely personal reasons. Adult
circumcision is usually performed in the outpatient setting by urologists.
However, family physicians who practice in isolated or rural areas and who are
adequately trained may also offer this procedure. All family physicians should
be prepared to advise their patients about the indications for adult
circumcision and, if necessary, make appropriate referrals for the procedure.

Indications and Contraindications

The most common indications
for adult circumcision are phimosis and paraphimosis.

Although there are numerous medical indications for adult circumcision,
none of them is very common.3 The most
frequent indication is phimosis, a tightness of the prepuce that prevents its
retraction over the glans.4 A patient may
also complain of pain with erection or during intercourse. Paraphimosis, the
unreplaceable retraction of a narrow foreskin that causes a painful swelling of
the glans, is the second most common indication for adult circumcision. Acute
paraphimosis is a urologic emergency requiring reduction of the foreskin
through surgical or nonsurgical methods. Recurrent balanitis and posthitis
(inflammation of the prepuce), preputial neoplasms, excessive prepuce
redundancy and tears in the frenulum are also medical indications for adult
circumcision.5

Patients may have social, religious or personal reasons for requesting a
circumcision.6 It is important to explore
these reasons with the patient to ensure that he has a thorough understanding
of the risks and benefits of circumcision and alternatives to the procedure.

There are no specific contraindications to adult circumcision in the
literature; however, patients with active infection, possible squamous cell
carcinoma of the penis or anatomic abnormalities of the external genitalia
should be referred for a urologic consultation.

Informed Consent

It is important to provide the patient with adequate information about the
procedure ahead of time. Specifically, the patient should be told about the
risks of bleeding, hematoma formation, infection, inadvertent damage to the
glans, removal of too much or too little skin, aesthetically unpleasing results
and a change of sensation during intercourse. The patient should also be
informed that, during the postoperative period, erections can cause pain and
disruption of the suture line that may require replacement of the sutures. Full
recovery following circumcision generally requires four to six weeks of
abstinence from all genital stimulation and sexual activity.

Full recovery following adult
circumcision may require four to six weeks of abstinence from all genital
stimulation and sexual activity.

The patient should also be reminded about the benefits of circumcision. If
he has the procedure, hygiene will be simpler and may result in fewer local
infections, resolution of phimosis and paraphimosis, and less risk of frenular
tears and bleeding during intercourse.

Alternatively, if the patient elects not to have the procedure, he should
be treated with conservative measures for these conditions (e.g., either oral
or topical antibiotics, training in meticulous hygiene for patients with
balanitis). Patients having a circumcision for recurrent balanitis should be
free from infection before the procedure.

Preparation of the surgical site includes a thorough surgical scrub of the
genital area with a povidone-iodine preparation. Shaving and clipping of the
pubic hair should be avoided to minimize the possibility of infection. Sterile
draping of the area should be used to identify the surgical field. An
electrocautery unit should be available to provide hemostasis.

Anesthesia

As with any surgical
procedure, bleeding and infection are probably the most common complications of
adult circumcision.

Anesthesia can be accomplished by administering a dorsal penile nerve
block, with or without a ring block.7 The
penis is innervated by the left and right dorsal nerves; these are branches of
the pudendal nerves.8 The dorsal penile nerve
is blocked by injecting a local anesthetic solution deep to Buck's fascia where
the nerves emerge from under the pubic bone. The patient is then placed in the
supine position. After preparation of the skin, two injection sites are
identified over the inferior edge of the pubic bone at approximately 10 o'clock
and 2 o'clock relative to the base of the penis. A 27-gauge, 1.5-in needle is
inserted, directed ventrally, until the pubic bone is contacted. The needle is
"walked" caudad off the pubis and through Buck's fascia. After
aspiration, 5 mL of local anesthetic is injected at each site. A mixture of
equal volumes of 0.5 percent bupivacaine (Marcaine) and 1 or 2 percent
lidocaine (Xylocaine) without epinephrine provides rapid onset of anesthesia of
suitable duration for circumcision.

As an option, to guarantee adequate anesthesia to the ventral surface and
frenulum, a ring block can also be performed. A ring block is a circumferential
subcutaneous injection at the base of the penile shaft using a 26- or 27-gauge
needle and approximately 10 mL of the anesthetic solution mentioned previously.
If the ring block is used in addition to the dorsal nerve block, lidocaine
toxicity can be a concern, since a total of 200 mg might be used if 10 mL of 2
percent lidocaine is administered. According to the 1998 Physicians' Desk
Reference, the maximum recommended dose of lidocaine without epinephrine is
4.5 mg per kg or approximately 300 mg, although for safety's sake, 200 mg is a
better maximum total dose.9

Potential complications are rare and include hematoma formation and
intravascular injection of local anesthetic.10
Use of an anxiolytic agent may also be considered. Diazepam
(Valium), 5 mg given orally one hour before the procedure, is effective. A
eutectic mixture of local anesthetics (e.g., EMLA cream) applied to the skin at
the base of the penis 30 to 60 minutes before the injections may decrease the
pain associated with the needle sticks.

This technique is preferred for use in patients with phimosis or
paraphimosis. In the patient presenting with acute paraphimosis, gentle, steady
pressure on the prepuce decreases the swelling. The physician may then reduce
the paraphimosis by pushing on the glans with the thumbs and pulling on the
foreskin with the fingers.11 If this step is
unsuccessful, the dorsal slit can be performed to relieve the pain, and the
remainder of the circumcision can be performed at a later time.

To perform the dorsal slit, the physician needs to identify the corona of
the glans and determine the extent of the dorsal slit. This is the most
important step in removing the correct amount of prepuce. The slit should
extend from the meatal opening 75 percent of the distance to the corona.
Counter-traction on the edges of the foreskin while the physician makes the
slit with scissors is helpful (Figure 1). The preputial skin should then
be held perpendicular from the shaft of the penis and excised at its base with
scissors (Figure 2). Large superficial veins are then ligated.

The frenulum is reapproximated first, as it can be a site of problematic
bleeding. We prefer to use a subcutaneous "U" stitch for good
cosmesis and to help avoid bleeding (Figure 3). The cut edges of the
foreskin are closed with multiple simple interrupted stitches using 4-0 or 5-0
absorbable sutures (chromic: Dexon or Vicryl) spaced evenly every 4 to 7 mm
(Figure 4). Excess bleeding is controlled with direct pressure and
electrocautery. A sterile dressing of petroleum gauze can then be applied over
the sutures.

The sleeve resection technique is adaptable for use in both children and
adults. In adults, the dorsal penile block, as described previously, is
adequate for anesthesia. A skin marker is used to delineate the incisions
(Figure 5). The external preputial incision is outlined over the corona
and the "V" of the frenulum on the ventral side. The internal
preputial incision is marked approximately 1 cm proximal to the coronal sulcus.
It is important to apply gentle pressure on the prepubic fat pad at the base of
the penis while making the initial outlines so the correct amount of skin will
be removed.

The external preputial incision should be made using a scalpel and
continued to Buck's fascia. After retracting the foreskin, a second incision
should be made in the inner prepuce. This internal incision should be carried
straight across the frenulum, as this area tends to retract distally, forming
an inverted "V." A "sleeve" now exists between the two
incisions (Figure 6). Hemostats should be placed dorsally for traction.
Subcutaneous attachments are then separated between Buck's fascia and the
prepuce. The sleeve should then be excised with electrocautery (Figure
7), and excess bleeding should be controlled by ligature or electrocautery.
The frenulum is then reapproximated initially with the "U" stitch
(Figure 3). Four quadrant sutures should be placed on the dorsum and
both sides, and the remaining interrupted sutures should be placed at 4- to
7-mm intervals (Figure 8). Excess bleeding may be controlled with direct
pressure and electrocautery. A sterile dressing of petroleum gauze can then be
applied over the sutures.

Complications

As with any surgical procedure, bleeding and infection are probably the
most common complications of circumcision in adult patients; however, accurate
statistics are not available.3 Other
complications include hematoma formation, diffuse swelling, pain from
inadequate anesthesia, poor cosmesis, tearing of the sutures due to erection
before healing is complete and anesthetic complications. Some patients may also
note an unpleasant heightened sensitivity during intercourse. Infection can be
treated with local or parenteral antibiotics, depending on the severity of the
infection. Bleeding can be controlled with pressure, an absorbable gelatin
sponge product (i.e., Gelfoam), electrocautery or ligatures. None of these
techniques can be preferentially recommended based on differences in
complication rate or severity.

Postoperative Care

While many physicians use no dressing at all following adult circumcision,
either petroleum jelly and sterile gauze or Xeroform petrolatum gauze can be
wrapped circumferentially around the sutured area, followed by sterile gauze
and lightly wrapped with self-adherent stretch gauze (Cobain). The dressing
should be removed 24 to 48 hours after surgery, after making sure that there is
no bleeding or oozing. At this point, no further dressing is necessary, and the
patient should be instructed to wear loose-fitting briefs. The patient should
also be advised to gently wash the wound daily for the next five to seven days;
after that, he may shower regularly. Intercourse and masturbation should be
avoided for four to six weeks after the procedure to prevent breakdown of the
wound. One ampule of inhaled amyl nitrate can be used as abortive therapy for
erections that occur during the recovery period.

The opinions contained herein are
those of the authors and should not be construed as official or as reflecting
the views of the Department of the Navy or the Department of Defense.

JOHN R. HOLMAN, CDR, MC, USN,
is a fellow in faculty development at Madigan Army Medical Center, Tacoma,
Wash., and a clinical faculty member in the Department of Family Medicine at
the University of Washington School of Medicine, Seattle. A graduate of the
University of Nevada School of Medicine, Reno, he completed a residency in
family practice at Naval Hospital, Camp Pendleton, Calif.

KEITH A. STUESSI, LT, MC, USNR,
is a third-year resident in family practice at the Puget Sound Family Medicine
Residency at Naval Hospital, Bremerton, Wash. Dr. Stuessi received a medical
degree from the University of Wisconsin Medical School, Madison.

Address correspondence to John R.
Holman, M.D., Faculty Development Fellowship, Department of Family Practice,
Madigan Army Medical Center, Tacoma, WA 98431. Reprints are not available from
the authors.